INCARCERATED HERNIA

Question 1

Approach to the critically Ill Incarcerated Hernia

Answer 1

Fluid bolus 20 ml / kg

Maintenance Fluid D5 0.45% NS

4 cc/kg/hr for 1st 10 kg
2 cc/kg/hr for 10-20 kg
1 cc/kg/hr for every kg > 20 kg

KCl @ 0.5 mEq/kg/hr IV

Serum potassium <3mEq/L give total of 1 mEq/kg (up to adult dose)
Serum potassium 3-3.5 mEq/L give 0.2 mEq/kg and recheck

Obtain i-STAT labs, including glucose.

Analgesia:
morphine 0.05-0.1 mg/kg IV
OR
fentanyl 1 μg/kg IV

Ondansetron:
2 mg < 15 kg
4 mg > 15 kg
8 mg > 30 kg

Ceftriaxone:
50 mg/kg intravenous or intramuscular every 12 hours (max 2000 mg)
PLUS
Metronidazole:
10 mg/kg intravenous every 8 hours (max 500 mg)

Pip-Tazo:
Age 2 months to 9 months: 80 mg/kg/dose (based on piperacillin component) intravenous every 8 hours (maximum dose: 3000 mg piperacillin)
Age >9 months, children, and adolescents weighing <40 kg: 100 mg/kg/dose (based on piperacillin component) intravenous every 8 hours (maximum dose: 3000 mg piperacillin)
Children and adolescents weighing >40 kg: 3000 mg piperacillin intravenous every 6 hours

Early Surgical Consultation

Question 2

Pathophysiology / Key Poinst

Answer 2

Failure of the patent process vaginalis to close -> indirect hernia

M6 : F1

Higher risk in preterm infants

Question 3

History & Physical

Answer 3

Preterm

Male

1st year of life

Groin & abdominal pain

Vomiting

Abdominal Distension

Mass / bulge in lower abdomen or groin

Smooth, firm, sausage shaped mass in groin + mild tenderness + erythema

Persistent swelling, crying, fever, refusal to eat + vomiting -> bowel incarceration

Check testicles for venous congestion

Question 4

Management: Manual Reduction

Answer 4

Manual reduction should be attempted with an incarcerated hernia in consultation with surgery:

-place in trendelenburg
-ice pack groin 10-15 min
+/- analgesia (morphine 0.05-0.1 mg/kg intravenous) and sedation
-gentle slow pressure to reduce
-guide proximal hernia through facial defect while providing firm gentle pressure on distal hernia until fully reduced
-if unsuccessful “pull” hernia to straighten & slip back into abdomen

+/- Ultrasound to confirm reduction

Question 5

Investigations

Answer 5

Ultrasound

Abdominal XRAY for suspected perforation

Question 6

Disposition

Answer 6

Post reduction monitor in ED for peritoneal signs or persistent vomiting

Successful reduction: outpatient surgical consultation

Unsucessful reduction: immediate surgical consultation

Ovarian herniation requires surgery